Northern Beaches Amputee QI project Review of NSW hospitals acute lower limb amputee protocols and treatment practices Katherine Henry – Physiotherapist Manly and Mona Vale Hospital Katie Lee – Physiotherapy Manager at Manly, Mona Vale and Hornsby Hospital

Amputee Project Issue: No formal acute lower limb protocol at NBHS and wide variety of treatment options regarding physiotherapy. Physiotherapists with different levels of amputee experience Using the contacts from : Enable NSW Accredited Amputee Clinics List, AustPar Website and Acute NSW hospital lists Contacted 41 different hospitals around NSW Of the 41: 1 never replied to multiple calls, messages and emails 2 were paediatric hospitals and excluded 9 were outpatient/day rehab/slow stream or had no involvement in acute rehab

Amputee Project In total: 29 eligible hospitals At each hospital, spoke with a Physiotherapist involved in acute amputees or had extensive knowledge of acute amputees Used a standard questionnaire and flow chart Each participating physio was asked their reasoning behind their acute amputee care choices and their direct quotes recorded

Amputee Project Of the 29 eligible and who were in contact, they were asked about: Protocol Standing Balance and Equipment Lower Limb Exercises in Standing Rigid Dressings Prone Lying STS and Equipment Limits on STS Hopping Private and Public Acute and Rehab hospitals Included if they treated amputee patients within first 2 weeks post-op

Amputee Project – Do you have a Protocol? Of the 29 involved in the survey, two thirds DID NOT have a protocol Most found the reason for this is that they had several doctors with differing treatment options and therefore majority had guidelines or recommendations

Standing Balance

Standing Balance Why its done: All who tolerate, except bilateral amputees Preparation for prosthesis To prepare for independent transfers and mobility Strengthen intact leg and core As per doctors/surgeons protocol It’s Functional Always standing balance Definitely Important, especially for AKA to learn how to stand, as they will need to put their prosthesis on in standing Need to get them going Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Standing Balance Equipment

Standing Balance Equipment Why FASF? Only Equipment available on acute wards Surgeon preference Guidelines recommend it Why Parallel Bars Easier Why Other Equipment? Want vascular patients to use the rail and crutches Finding Standing Table Best FASF can hurt shoulder and can be a falls risk Rehab preference not to use FASF Overall, FASF were generally regarded as a good place to start when choosing standing equipment and then quickly progressed to PUF Vascular amputees were singled out here with specific instructions that they are NOT to use FASF Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Lower Limb Exercises in Standing

Lower Limb Exercises in Standing Why Not? Spend most time lying in bed Not routinely, if falls risk, will not use Surgeons limit this, won’t allow them to SOOB or attempt mobility Tend to do bed exercises initially due to older population Standing balance may be an issue If patient is a falls risk, will not use More Supine and seated (including Swiss ball) exercises initially Can’t with Bilateral amputees Co-morbidities Limited time Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Lower Limb Exercises in Standing Why? Everyone does it Surgeon preference Strengthen Done with Exercise Physiologist* Strength in standing is important, the earlier the better Protocol Improves standing tolerance Increased blood flow to the stump to desensitise associated pain Physiological benefits of standing Psychological benefits of standing * Private Hospital Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Rigid Dressings

Rigid Dressings Why? Recommended best practice in NSW Health Amputee Care Standards Protection and safety issues Vascular team wants them Day 5, ortho team Day 2 Policy of Surgeon Good support from surgical team, they put it on in theatre Used with silicone liners to assist healing * Protection of stump * Private Hospital Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Rigid Dressings Why Not? Biggest Issue with amputees Policy of Surgeon* Not done in acute hospital and therefore too late to be done in rehab Depends on the vascular surgeon Surgeon wants only a back slab to prevent contractures Only 1 surgeon wants it but the other 5 surgeons don’t Depends on level of experience of physio on ward, had issues with junior or in- experienced physios in past causing complications when it has been done Surgeons want to view the wound * Main reason given for Rigid Dressings not being done Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Prone Lying

Prone Lying Don't do it as routine If allowed, surgeons restrict this Why Not? Don't do it as routine If allowed, surgeons restrict this Patients find it too difficult Limited by drain(s) or attachments Limited physiotherapy treatment time Why? Of course As soon as medically stable Protocol Will always try to get into prone but it can be difficult Stretches the hip, minimise hip flexion contracture Surgeon preference Try and persist with it Best on double plinth Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

STS practice

STS practice Why Why Not? Transfers is primary goal Definitely Tonnes, main exercise Improve unaffected limb strength and endurance They do it on acute but don’t in rehab Surgeon preference Start of functional training Why Not? Time poor on acute wards Not routinely Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

STS practice Equipment Very Similar to standing balance equipment reasons

Any Limits on STS practice? This category we only added after making the initial calls Therefore this category is only out of 20, so we have 9 hospitals not asked Of the 20 asked, 95% did NOT have limits on STS

Hopping Of those asked, 80% said YES to hopping This category we only added after making the initial calls Therefore this category is only out of 20, so we have 9 hospitals not asked Of the 20 asked, 80 % said YES to hopping Of those asked, 80% said YES to hopping

Hopping Why hopping? Why No hopping? Long distance if tolerated Definitely Got to hop, haven’t they? Surgeon preference Limit to 10m max, short distances to and from bathroom Don’t want them relying on w/chair Why No hopping? Rehab preference for patient not to hop if going to get a prosthesis May not need it in future Not a natural gait Dangerous if they fall Please note: Above are direct quotes provided by the acute care amputee physio at the participating hospitals

Preferred Transfer Method Most stated that they will try the standing transfer first and then try pivot or slide board next Some felt that the Slide board is under utilised In the pre-op phase some mentioned that they arrange amputee equipment with the OT prior to the operation including: w/chair, slideboard etc. They stated they work closely with the OT on Day 1 and often do the first transfer with the OT.

Acute or Rehab Hospital

Public or Private Hospitals

Amputee QI project Outcomes and recommendations for NBHS: Should work on Standing Balance with FASF, PUF or parallel bars (if available) Should work on Lower Limb Ex in Standing Should do Rigid Dressings Should do Prone Lying Should do STS practice with FASF or parallel bars (if available) and use clinical judgement for limits Should do hopping, if appropriate and using clinical judgement Should try Standing Transfer initially but if can’t manage, use clinical judgement and try pivot or slide board Scope to involve more OT input in the acute phase If Northern Beaches were to follow how the majority of NSW acute care amputee physiotherapist were treating their patients, we would be following the above outcomes of the project

How could this Project have been improved? Expanding the questionnaire to involve: Age of amputees (average or range) Number of amputees at the hospital each year Average level at which amputations occur Reasons for the amputations Asked the same questions to those treating amputees in the rehab phase Could have questioned the relationship of the physiotherapists with the surgeon or surgeons, as it became clear (especially with rigid dressings) that those with good communication, open dialogue and discussion expressed positive outcomes for their patients

Future of Acute Amputee Care on the Northern Beaches Currently, using this information (including Amputee Care Standards) to help develop an acute amputee protocol in discussion with the surgeons and other involved medical and allied health staff Protocol will be focused on Acute Amputee Care at Manly and Hornsby Increased support for this protocol to meet with Amputee Care Standards and to improve outcomes of amputee patients at Manly and Hornsby

Questions?